Tag Archives: Senate

Tom Scully, the outspoken former head of Medicare, recently said that one of the biggest mistakes policymakers made when redesigning the physician payment system in the early 1990s was giving the American Medical Association control over the Relative Value Scale Update Committee or the RUC.

The RUC, which is as controversial as it is unknown, is a 29-member panel that makes recommendations on how to value of thousands of physician services under Medicare. While Medicare officials are under no obligation to accept the panel’s decisions, most of the time that’s exactly what they do.

Courtesy Wikimedia Commons/ Public Domain.

Mr. Scully told members of the Senate Finance Committee that the current RUC structure, as run by the AMA, isn’t objective enough. There’s a lot on the line since the RUC’s decisions impact about $80 billion in Medicare spending each year, he said. As lawmakers consider how to reform the physician payment system, he urged them to also think about ways to make the RUC less political and more independent.

The comments in the Senate hearing room were just a sampling of the criticism that the AMA and the RUC have received recently. Over the past year or so, the RUC has been under near constant attack from a small group of primary care physicians who are suing the Centers for Medicare and Medicaid Services with the goal of getting the agency to dump the RUC. Their contention is that the RUC is biased toward subspecialists and that the panel’s recommendations have contributed to a significant gap between primary care and specialty pay.

The AMA has continued to support the RUC process, arguing that a group of physicians is best positioned to determine the value of medical services and that the panel has often championed payment increases for primary care services.

“We will amend the criteria to make clear that disqualifying investigations must be criminal and conclusive in nature and not political,” Komen CEO and founder Nancy Brinker said in a statement issued Friday.

The uproar brought more than $3 million in donations to Planned Parenthood in just three days, but also highlights the volatile mixture of politics and medicine.

Dr. Richard Carmona recently observed that one of the most popular presentations he made during his tenure as the 17th Surgeon General of the United States did not address emerging infections, physical trauma, or national diasters, but rather the plague of politics in medicine.

“This traumatic plague of politics is more insidious and virulent than emerging infections; has potentially more morbidity and mortality than hemorrhagic shock or blunt or penetrating trauma; has virtually no diagnostic criteria; and is resistant to all therapy, especially voices of reason, substantive discussion or positions of compromise,” he said during a memorial lecture at the recent meeting of the Eastern Association for the Surgery of Trauma.

Dr. Richard Carmona Patrice Wendling/Elsevier Global Medical News

Dr. Carmona didn’t have far to look for examples to flesh out his diagnosis.

More than a century ago, public health officials’ efforts to control the bubonic plague outbreak of 1900 in San Francisco were nearly derailed by politicians who claimed that quarantine procedures, including closing the city’s harbor to incoming ships, were an over-reaction that would impede commerce and tourism, and result in the collapse of San Francisco, and possibly California. The Surgeon General who intervened based on the scientific evidence was labeled a heretic and asked to resign.

In the 1980s, similar calls were made after former Surgeon General Dr. C. Everett Koop refused to back down from statements that HIV could be prevented. At the time, Dr. Carmona reminded the audience, senior elected officials were telling the American public that HIV was God’s way of punishing homosexuals.

In the 1990s, the tenure of Surgeon General Dr. Joycelyn Elders was cut short after controversy erupted over a 1994 speech at the United Nations World AIDS Day that included remarks that masturbation was a normal part of sexuality and that abstinence-only education was “child abuse.”

During his own term under President George W. Bush, Dr. Carmona said, abstinence-only became the mantra of the administration, “based solely on ideological and theological concepts, and not science.

“Science had really demonstrated that abstinence alone was a failed proposition,” Dr. Carmona said. “Ironic, that an administration that was repeatedly caught up in the issue of abortion did not see the connection that comprehensive sex education was the best method to prevent STDs, unwanted pregnancies, and therefore abortions. As Surgeon General, this is a science-based position I have always held.”

Dr. Carmona, the only Surgeon General to be unanimously confirmed to the position in over 200 years, said the trauma of politics and its preventable deleterious outcomes are owned equally by politicians on both sides of the aisle.

He pointed out that over-the-counter sales of Plan B stalled under the Bush administration before gaining limited approval in December 2006, but fared no better seven years later under the more liberal Obama administration. In December 2011, HSS Secretary and Democrat Kathleen Sebelius overruled the FDA’s decision to make the emergency contraceptive available, without prescription, to girls of all childbearing ages. While Sebelius cited a lack of conclusive data, Dr. Carmona said it was the administration’s desire to avoid a political battle in the face of an upcoming election.

“The immunization for preventing the continued viralness of political trauma is transparency, full disclosure, accountability for elected officials, a citizenry that is informed and participatory, coupled with civil discourse of complex issues,” he said.

There’s a lot at stake in the negotiations over raising the nation’s debt limit, from the impact on the global economy to the potential elimination of Medicare’s Sustainable Growth Rate (SGR) formula. That’s right, the much-despised SGR, which is used in determining physician payments under Medicare, has even made its way into the talks about increasing the debt ceiling.

House Speaker John Boehner (left) and Senate Majority Leader Harry Reid (right) met with the President on July 10 to discuss the debt limit. Official White House Photo by Samantha Appleton.

As the president and congressional leaders go into overdrive, holding daily meetings on ways to trim the deficit, the medical establishment is pushing hard for lawmakers to stop the cycle of threatened physician pay cuts followed by last-minute legislative Band-Aids. The American Medical Association, along with more than 100 state and medical specialty societies, recently sent a letter to lawmakers warning that the cost of an SGR fix will only go up. Right now, they estimate the 10-year cost of replacing the SGR is nearly $300 billion, but that figure could rise to more than $500 billion in just a few years, they wrote. The debt ceiling legislation provides “the best—and perhaps only—opportunity to ensure stability in Medicare payments, ensure continued beneficiary access to care, and address the SGR deficit in a fiscally responsible manner,” the organizations wrote in their letter.

Get the full scoop on the SGR in this week’s Policy and Practice Podcast.

A new report from the U.S. Government Accountability Office (GAO), the auditing arm of Congress, found that the Food and Drug Administration isn’t doing everything it can to learn from medical device recalls. That’s despite the fact that on average more than 700 medical devices are recalled each year. The report was requested by Sen. Chuck Grassley (R-Iowa), the chairman of the Finance Committee and Sen. Herb Kohl (D-Wisc.), the chairman of the Committee on Aging.

The GAO investigators didn’t take issue with what the FDA does in initiating and classifying the mostly voluntary recalls of medical devices. Instead, they wrote that the agency took a haphazard approach to assessing the effectiveness of recalls and analyzing information after a recall. Those gaps represent a missed opportunity to learn went wrong and keep it from happening again, the GAO warned.

Specifically, because of the FDA’s lack of analysis on medical device recalls, they couldn’t give definitive answers to questions from the GAO about the common causes of recalls, the trends in the number of recalls over time, the variation in recalls by risk level, the types of devices and medical specialties that account for the most recalls, and the length of time it takes for companies and the FDA to complete recall activities.

But the FDA told the GAO investigators that it does use recall information help target their inspections. And the GAO gave FDA a gold star from use of recall information to detect and address safety issues with automated external defibrillators. Late last year, the FDA held a conference on AEDs where in presented historical recall data to make the case for safety improvements in the device, the GAO wrote.

For its part, the FDA says it’s getting better. In statement in response to the GAO report, FDA officials said that last year launched the Recall Process Improvement Project, which is aimed at better educating the industry about the recall process. And about a year ago, the FDA began using recall data to aid in the review of devices. The agency has also developed initiatives that use recall data to help improve the safety of infusion pumps, external defibrillators, and radiation from medical procedures.

Doctors know that the Medicare physician payment system is broken. Lawmakers know it. Maybe even some patients know it, too.

The problem is how to fix it so that it doesn’t bust the federal budget. And if lawmakers choose to replace the Sustainable Growth Rate (SGR) formula, which is currently used to determine physician payments under Medicare, they will face another challenge: choosing a new formula that won’t create the same problems in a few years.

Medicare payments could fall off a cliff if Congress doesn't act this year. Image via Wikimedia from User Urban.

The Medicare Payment Advisory Commission, which advises Congress on all things Medicare, has come out with a new report that outlines several alternatives to the SGR. In its report, MedPAC tells lawmakers that by replacing the SGR with a structure that doesn’t have scheduled payment cuts to doctors, they would have the chance to adopt other payment changes that could save the system money.

For example, in exchange for across-the-board pay increases to physicians, Medicare officials could reduce payments for specific services that are overpriced, they wrote. Or they could shift payments away from procedures and toward services that promote care coordination and population health.

Get all the details on the SGR, Medicaid reform options, and the 2012 GOP presidential field in this week’s Policy & Practice podcast.

It was a very bumpy road for the Obama administration to get the Affordable Care Act passed. And if it hadn’t been for a few key developments, it may never have happened at all, according to Dr. Bob Kocher, an internist who currently works for the Center for U.S. Health System Reform at McKinsey & Company. He was previously a member of President Obama’s National Economic Council and was involved in the effort to formulate and pass health care reform.

At the Society of Hospital Medicine’s annual meeting in Grapevine, Tex., this week, Dr. Kocher told thousands of hospitalists just how tough it was to get the Affordable Care Act passed, even with Democrats in control of both the House and the Senate. Health care advisors in the White House started out by trying not to repeat the mistakes of the past, he said. “The System,” the book recounting just how Hillary Clinton’s health care plan had derailed, was required reading. But despite their best intentions, they made many mistakes anyway, Dr. Kocher said.

Official White House photo by Chuck Kennedy.

The rest of the story is well known. The original health care reform bill passed through the House in November 2009. The Senate passed their version of the bill on Christmas Eve. A small group of Democratic lawmakers immediately set to work negotiating a new piece of legislation that would combine elements of the two plans and that would again have to be passed by both chambers. But with the election of Massachusetts Republican Scott Brown to the Senate in January 2010, the administration’s hopes of getting another bill passed through the Senate were dashed. The House Speaker agreed to try to pass the Senate’s original bill through the House instead. But even that wouldn’t have been enough to save health reform if not for a couple of events that happened outside of Congress, Dr. Kocher said.

First, Anthem Blue Cross of California proposed a massive 40% rate hike in the individual insurance market in the weeks before the pivotal second House vote. The proposal garnered headlines, and the Obama administration jumped on the chance to highlight it as a reason to reform the health insurance system. And then Sister Carol Keehan of the Catholic Health Association came out in support of the bill, saying it did not allow for federal funding of abortions, and concerns about the issue could be allayed by an executive order from the President. This gave some anti-abortion Democrats a bit of breathing room to support the bill.

Looking back, Dr. Kocher said administration officials might not have made health reform a top domestic priority if they had known it would take so long to pass and cost them so much politically. He said he’s glad he didn’t know.

In the next couple of days Congress will finally vote on a budget to fund the federal government for the rest of this year. But the work is only just beginning. Before the President’s signature is dry on that legislation, Congress will begin hashing out the budget for 2012. House Budget Commitee Chairman Paul Ryan (R- Wisc.) recently unveiled the GOP plan for 2012, which calls for a repeal of the Affordable Care Act, along with a total overhaul of the Medicare and Medicaid programs.

Photo by Alicia Ault.

Under the plan, the federal government would convert its share of Medicaid funding into block grants for the states. As for Medicare, the program would stay the same for current retirees and those nearing retirement age. However, for everyone who is age 54 and younger today, the plan calls for privatizing the program. Republicans are touting the plan as responsible budgeting, but many Democrats say it will destroy social safety net programs.

Hear more about the brewing budget fight, physician pay, and malpractice reform legislation in this week’s Policy & Practice Podcast. Take a listen: